Malpractice Case: Are You Sure the Patient Received the Test Results?

Gordon T. Ownby


September 12, 2018

Medscape Editor's Key Points:

  • Any delay in giving patients results increases the chances that the patient will not get the information, whether from missed appointments, unreturned phone calls, misplaced charts, or computer glitches.

  • A fail-safe plan is needed to alert the patient of any test results.

  • Office staff members should keep track of when they call patients, how often they called, and whether they actually spoke with the patient.

The Case

When reporting significant test results, physicians may certainly develop their own parameters so that their patients get the information in the proper context and can get their questions properly addressed. Any delay in getting the results to the patient, however, increases the odds of the message getting lost in the shuffle.

A 54-year-old woman visited a community health clinic with complaints of headaches, back pain, and joint pains. A family practitioner at the clinic assessed benign hypertension, depressive disorder, insomnia, general osteoporosis, and lower back pain. The physician prescribed antidepressives and saw her on a number of subsequent visits for complaints of anxiety, depression, panic attacks, and difficulty sleeping.

The next year, the family practice physician referred the patient to Dr N, a neurologist. The patient described to Dr N daily headaches and a diffuse, pressing pain. She also complained of appetite and weight loss, tremors in the arms and lower extremities, low energy, shortness of breath, sudden onset of chest pain, constant fear, delusional ideas, and isolation. Dr N noted that the patient had chronic daily headaches secondary to chronic depression, anxiety and panic attacks, hypertension, and goiter. Dr N recommended a CT scan to rule out a mass lesion, prescribed Prozac®, and further suggested psychiatric and endocrinology consultations. They scheduled a follow-up appointment for two weeks.

In the interim, the patient underwent a brain CT scan at a local hospital. The radiologist noted a 4.5-cm left temporal lobe mass that was either a brain tumor or meningioma and suggested an enhanced CT or MRI for further evaluation.

The patient canceled her follow-up appointment with Dr N and instead started a round of visits with another family practitioner whom she had seen years earlier. Several weeks later, the patient returned to the community clinic for depression and increased anxiety. The chart of the referring physician did not reflect Dr N's consultation or the CT report.


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